A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

Schedule elective cesarean delivery

Perform bimanual pelvic examination

Perform emergency cesarean delivery

Administer oxytocin to induce labor

A 35-year-old patient is brought into the emergency department post motor vehicle crash. Stabilization of the patient in the trauma bay requires endotracheal intubation. The patient has a laceration on the femoral artery from shrapnel and seems to have lost large quantities of blood. The patient is transfused with 13 units of packed red blood cells. His vitals are T 96.5, HR 150, BP 90/40. Even with the direct pressure on the femoral artery, the patient continues to bleed. Results of labs drawn within the last hour are pending. Which of the following is most likely to stop the bleeding in this patient?

Fresh frozen plasma and platelets

A 34-year-old primigravida was brought to an obstetric clinic with a chief complaint of painless vaginal bleeding. She was diagnosed with placenta praevia and transfused with 2 units of whole blood. Five hours after the transfusion, she developed a fever and chills. How could the current situation be prevented?

Transfusing leukocyte reduced blood products

Administering prophylactic epinephrine

ABO grouping and Rh typing before transfusion

Performing Coombs test before transfusion

Administering prophylactic immunoglobulins

A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

Perform uterine massage and administer oxytocin

Manually remove retained placental fragments

Perform uterine artery embolization

A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?

Hysteroscopy with potential adhesiolysis

Measurement of serum FSH and LH concentrations

Measurement of antisperm antibody concentration

Estrogen/progestin withdrawal test

Postpartum hemorrhage protocols — USMLE Lesson

PPH Protocols - The First Five Minutes

HELP: Activate PPH protocol. Call for anesthesia, OR staff, blood bank.
Massage: Begin vigorous fundal massage; add bimanual compression.
Access: Secure 2 large-bore IVs. Draw labs (CBC, coags, type & crossmatch).
Medicate: Administer first-line uterotonics.
- Oxytocin: 20-40 units in 1L crystalloid IV.
Assess: Systematically evaluate for the 4 T's.

⭐ Uterine atony is the most common cause of PPH (~80% of cases). Fundal massage is the initial step to address it.

PPH Management: Compression Techniques

Uterotonic Meds - Tone Up the Uterus

First-line therapy to increase uterine tone and control bleeding. Administer immediately after placental delivery if atony is suspected.

📌 Mnemonic: Oh My Cramping Misery

Drug	Mechanism	Route & Dose	Contraindications
Oxytocin	Activates oxytocin receptors	IV: 20-40 units in 1L fluid	None (use with caution)
Methylergonovine	Ergot alkaloid, potent vasoconstrictor	IM: 0.2 mg	⚠️ Hypertension, preeclampsia
Carboprost (Hemabate)	Prostaglandin F2α analogue	IM: 0.25 mg	⚠️ Asthma
Misoprostol	Prostaglandin E1 analogue	Rectal: 800-1000 mcg	None (use with caution)

⭐ Exam Favorite: Always check blood pressure before giving methylergonovine. Its vasoconstrictive effects can be dangerous in patients with hypertension or preeclampsia, making it a critical contraindication to remember.

Refractory PPH - When Meds Don't Work

When uterotonics fail, escalate management from least to most invasive. The goal is to stop hemorrhage while preserving fertility if possible. Interventions range from temporary tamponade to definitive surgical procedures.

Uterine Tamponade: Bakri balloon applies direct pressure to the bleeding surface. Buys time and can be definitive.
Interventional Radiology: Uterine Artery Embolization (UAE) is highly effective if the patient is hemodynamically stable.
Surgical: For unstable patients or when other methods fail.

B-Lynch Suture Placement for Postpartum Hemorrhage

⭐ The B-Lynch suture is a key fertility-sparing surgical option. It mechanically compresses an atonic uterus, functioning like a "uterine seatbelt" to control bleeding.

Transfusion Strategy - The Great Blood Bailout

Activate Massive Transfusion Protocol (MTP) for hemodynamic instability or ongoing severe hemorrhage (EBL >1500 mL).
📌 Mnemonic: Call the blood bank at 1-1-1 (PRBCs:FFP:Platelets).

Transfusion Goals:
- Hgb >7 g/dL
- Platelets >50,000/μL
- Fibrinogen >200 mg/dL
- INR <1.5

⭐ Per the WOMAN trial, administer Tranexamic Acid (TXA) early: 1g IV within 3 hours of birth. Reduces death due to bleeding.

Massive Transfusion Protocol Cooler

High‑Yield Points - ⚡ Biggest Takeaways

Uterine atony is the #1 cause of PPH; initial steps are fundal massage and oxytocin.

Second-line uterotonics include methylergonovine, carboprost, and misoprostol.

Contraindications are key: avoid methylergonovine in hypertension and carboprost in asthma.

Administer tranexamic acid (TXA) within 3 hours if bleeding persists despite uterotonics.

For massive hemorrhage, activate massive transfusion protocol (MTP) with a 1:1:1 ratio of PRBCs:FFP:platelets.

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